CASE PRESENTATION

A. PATIENT IDENTITY
Name
: Mr.K
Age
: 57 years old
Sex
: Male
Address
: Tegal Karang
Religion
: Islam
B. ANAMNESIS
Main Grievance
Swollen scrotum

Historical of Present Disease

6 months prior to admission, patient noted that his scrotum has been swollen.
There isn`t any associated tenderness. There werent complains about fever,breathing
difficulty,cough,nausea nor vomit.

Historical of Past Disease

Hypertension (-)
Diabetes Melitus (-)

Historical of Family Disease

There are no other family members who have same disease with the patient.

C. MEDICAL EXAMINATION
Present Status
General Condition
: moderate
Awareness
: Compos mentis
Blood Pressure
: 120/80
Pulse
: 88 x/minute
Breathing
: 21 x/minute
Temperature
: 36,8 C

General Status
Head
Form
Hair
Eye

Ear
Nose
Mouth

: Normal, Simetrical
: Black Colour, No hair fall
: Anemic Conjungtival -/Icteric Schlera -/Light Reflex +/+
Isocor pupil
: Normal form, cerumen (-), intact tympani membrane
: Normal form, No septum deviation, epitaction -/: Normal

Neck
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 Enlargement of lymph nodes (-)

Trachea in the middle
No mass
Thorax

Lungs - pulmonary
Inspection
Palpation

: The chest shape is symmetrical both ofleft and right

: Fremitus tactile and vocal symmetrical right and left,
crepitus (-), tenderness (-), rebound tenderness (-)
Percussion
: Sound of resonant in both lung fields
Auscultation : Sound of vesicular and bronchial the entire lung field,
ronchi -/-, wheezing -/-

Heart
Inspection
Palpation
Percussion

: Ictus cordisis not visible

: Ictus cordispalpable on the left midclavicula ICS line 5
: Upper limit ICS 3 lineaparasternalissinistra
Right limit ICS 4 lineasternalisdextra
Left limit ICS 5 lineamidclaviculasinistra
Auscultation : Heart sound 1 2 pure regular, murmurs (-), gallops (-)

Abdomen
Inspection
Palpation
Percussion
Auscultation

: flat abdomen shape, supple, not visible skin disorders

: tenderness (-), rebound tenderness (-)
: There was a whole field tympanic abdomen
: Bowel sounds (+) 4x/minute

Extremity
o Superior
o Inferior

: warm, Edema -/-, CTR < 2

: warm, Edema -/-, CTR < 2

Localized Status
Scrotum : soft nontender fullness within the hemiscrotum. Transillumination (+)

D. INVESTIGATIONS
Laboratory Examination
11/8/2015
Test

Result

Normal Range

Hemoglobin

13,7 g/dl

12- 16 g/dl

Leukocyte

6.830 /uL

5200 12400 /uL

Hematocrite

39,6 %

37 47 %

Trombocytes

285.000 / uL

150.000-450.000/uL

Hematology

Radiology
Thorax photo : NORMAL
E. DIAGNOSIS OF WORK
Hydrocele communicans
G. MANAGEMENT PLAN
Infusion RL 20 GTT / min
Ketorolac 3 x 1
Ceftriaxon 3 x 1
H Prognosis
Quo ad vitam: ad bonam
Quo ad functionam: ad bonam
Quo ad sanationam: ad bonam

LITERATURE REVIEW
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Background
A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the
spermatic cord. These fluid collections may represent persistent developmental connections
along the spermatic cord or an imbalance of fluid production versus absorption. In rare cases,
similar fluid collections can develop along the canal of Nuck[1] in females.
Hydroceles pose little risk of clinical consequence. However, the potential for more than fluid to
appear within developmental connections between the abdominal cavity and the scrotum or the
association with underlying scrotal pathology requires that hydroceles be evaluated with due
prudence. See the image below.
History of the Procedure
The description of the abdominal cavity parietes to the tunica vaginales is attributed to Galen in
176 AD. However, the clear description of the inguinal anatomy and its relationship to groin
hernias and hydroceles was not recorded until the 19th century.
Problem
The presence of fluid within the hemiscrotum has little clinical impact on the testis. However,
determining the cause for the increased fluid, specifically any associated clinically significant
pathology, remains the primary concern with regard to hydroceles. Once pathology that is more
ominous has been excluded, persistence of the hydrocele or associated discomfort may indicate
the need for surgical intervention.
Patients who have undergone varicocelectomy may be an important exception in which a
hydrocele may be of clinical importance. This procedure, usually performed when dilated
vessels around the testes are believed to increase intratesticular temperatures, thereby leading or
contributing to male infertility, may damage nearby lymphatic vessels. This, in turn, may cause
the formation of postvaricocelectomy hydroceles in approximately 7% of patients, potentiating
the insulation of the testicle and leading to persistent problems with sperm production. The use
of microscopes during this procedure has significantly decreased the incidence of lymphatic
obliteration and, therefore, hydrocele formation.
Epidemiology
Frequency
Patent processus vaginalis are found in 80-90% of term male infants at birth. This frequency rate
steadily decreases until age 2 years, when it appears to plateau at approximately 25-40%.
Indeed, autopsy series of men have identified a frequency rate of 20% of the processus vaginalis
remaining patent until late in life. However, clinically apparent scrotal hydroceles are evident in
only 6% of term males beyond the newborn period. Certain conditions, such as breech
presentation, gestational progestin use, and low birth weight, have been associated with an
increased risk of hydroceles. The incidence of hydroceles in men is less well known.
Etiology
The causes of hydroceles are legion. In children, most hydroceles are of the communicating
type, in which patency of the processus vaginalis allows peritoneal fluid to flow into the
scrotum, particularly during Valsalva maneuvers.
In the adult population, filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts
for most causes of hydroceles worldwide, affecting more than 120 million people in more than
4

73 countries (see Hydrocele, Filarial). However, this condition is virtually nonexistent in the
United States, where iatrogenic causes of hydroceles predominate. Following laparoscopic or
transplant surgery in males, inadequate irrigation fluid aspiration may cause hydroceles in
patients with a patent processus vaginalis or a small hernia. Careful aspiration of fluid at the end
of laparoscopic procedures helps prevent this complication. In noncommunicating hydroceles,
for both children and adults, the balance between fluid production within the tunica and the fluid
absorption is altered.
A few studies have attempted to show a link between certain molecular derangements and an
increased incidence of patent processus vaginales (and therefore hydroceles and indirect
hernias). Two such examples include increases in maternal estrogen concentrations during
pregnancy and abnormalities in the calcitonin gene-related peptide (CGRP) released by the
genitofemoral nerve.[2]
Pathophysiology
The pathophysiology of hydroceles requires an imbalance of scrotal fluid production and
absorption. This imbalance can be divided further into exogenous fluid sources or intrinsic fluid
production.
Alternatively, hydroceles can be divided into those that represent a persistent communication
with the abdominal cavity and those that do not. Fluid excesses are from exogenous sources (the
abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop
increased scrotal fluid from abnormal intrinsic scrotal fluid shifts.
Communicating hydroceles
With communicating hydroceles, simple Valsalva maneuvers probably account for the classic
variation in size during day-sleep cycles. Nonetheless, with the incidence of patent processus so
great, why children with clinically apparent hydroceles are relatively few remains somewhat
inexplicable. Chronically increased intra-abdominal pressure (eg, as in chronic lung disease) or
increased abdominal fluid production (eg, children with ventriculoperitoneal shunts) probably
warrants early surgical intervention.
Noncommunicating hydroceles
Noncommunicating hydroceles may result from increased fluid production or impaired fluid
absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral
illnesses. In such cases, viral-mediated serositis may account for the net increased fluid
production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid
production due to underlying inflammation. Although rare in the United States, filarial
infestations are a classic cause of the decreased lymphatic fluid absorption resulting in
hydroceles.
Presentation
Hydroceles typically manifest as a soft nontender fullness within the hemiscrotum. The testis is
generally palpable along the posterior aspect of the fluid collection. When the scrotum is
investigated with a focused beam of light, the scrotum transilluminates, revealing a homogenous
glow, without internal shadows.
The inability to clearly delineate or palpate the testicular structures; the presence of tenderness,
fever, or any gastrointestinal symptoms (eg, vomiting, constipation, diarrhea); or the appearance
of internal shadows on transillumination should raise the suggestion of a different diagnosis or
some additional underlying pathology. Scrotal ultrasonography is the next logical step.
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Indications
Indications for intervention in hydroceles include the following:

Inability to distinguish from an inguinal hernia

Failure of the hydrocele to resolve spontaneously after an appropriate interval of
observation
Inability to clearly examine testis
Association of hydroceles with suggestive pathology (eg, torsion, tumor)
Pain or discomfort
Male infertility
Patient desire
Relevant Anatomy
The developmental anatomy of the inguinal canal is responsible for the genesis of pediatric
communicating hydroceles. As the testis descends from the posterolateral genitourinary ridge at
the beginning of the third trimester of fetal gestation, a saclike extension of peritoneum descends
in concert with the testis. As descent progresses, the sac envelops the testis and epididymis. The
result is a serosal-lined tubular communication between the abdomen and the tunica vaginalis of
the scrotum.
The peritoneum-derived serosal communication is the processus vaginalis, and the serosa of the
hemiscrotum becomes the tunica vaginalis. At term, or within the first 1-2 years of life, the
processus vaginalis of the spermatic cord fuses, obliterating the communication between the
abdomen and the scrotum. The processus fuses distally as far as the lower epididymal pole and
anteriorly to the upper epididymal pole. Failure of complete fusion may result in communicating
hydroceles, indirect inguinal hernias, and the bell-clapper deformity of abnormal testicular
fixation in the scrotum.[3]
Contraindications
Seemingly, no true absolute contraindications exist for repair of hydroceles. However, given the
minimal clinical consequence of the hydrocele itself, any condition that classifies patients as
poor surgical or anesthetic risk may be considered a relative contraindication to surgical repair.
Additionally, while a slight majority of pediatric surgeons across North America would repair
any communicating hydrocele (somewhat irrespective of age) if it were clearly communicating,
waiting until the child is aged 1-2 years is certainly reasonable. Finally, small atrophic testes, or
solitary testes, should be approached with great caution to minimize the risk of anorchia
Medical Therapy
Asymptomatic adults with isolated noncommunicating hydroceles can be observed indefinitely
or until they become symptomatic, as complications such as infection or testicular compromise
are exceedingly rare. However, if the diagnosis is in question or underlying pathology cannot be
excluded, operative exploration is warranted.
Lund et al, in a study of 76 patients with hydrocele testis, found that aspiration and sclerotherapy
with polidocanol is an effective treatment with a low recurrence rate. In this prospective, doubleblind, randomized study, 36 patients given polidocanol (group 1) were compared with 41
patients given placebo (group 2). Recurrence after the first treatment was seen in 16 (44%) of
the polidocanol patients and in 32 (78%) of the placebo patients. Recurrence after re-treatment
with polidocanol in both groups was seen in four patients (25%) in group 1 and in 14 patients
(44%) in the former placebo group. The overall success rate of treatment in group 1 was 89%.[5]
6

Surgical Therapy
Surgical therapy can be divided into three approaches. The first is an inguinal approach with
ligation of the processus vaginalis high within the internal inguinal ring and is the procedure of
choice for pediatric hydroceles (typically, communicating). If a testicular tumor is identified on
testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures
is mandated.
In a study by Saka et al, 69 patients with hydrocele underwent either laparoscopic percutaneous
extraperitoneal closure (40 patients) or open repair (29 patients), and the safety and efficacy of
the two approaches were compared. There were no significant differences in length of operation,
anesthesia, or complications for the two procedures; and no recurrences were observed for either
procedure.[6]
In addition, the authors reported on the features of the internal inguinal ring (IIR) found in cases
of hydrocele and in cases of inguinal hernia treated during the study period. In the cases of
hydrocele, 59.1% of the IIRs were narrow patent processus vaginalis (PPV) with a peritoneal
veil; for patients with inguinal hernia, 92% of the IIRs were widely opened PPV.[6]
The second is the scrotal approach with excision or eversion and suturing of the tunica vaginalis
and is recommended for chronic noncommunicating hydroceles. This approach should be
avoided upon any suspicion for underlying malignancy.
The third, an additional adjunctive, if not definitive, procedure, is scrotal aspiration and
sclerotherapy of the hemiscrotum using tetracycline or doxycycline solutions. Recurrence after
sclerotherapy is common, as is significant pain and epididymal obstruction, making this
treatment a last resort in poor surgical candidates with symptomatic hydroceles and in men in
whom fertility is no longer an issue.
Preoperative Details
Preoperative considerations are minimal because outpatient treatment is the routine. Nothing by
mouth (NPO) provisions are age- and institution-dependent. Proper provisions for postoperative
transportation and observation are arranged prior to surgery.
Intraoperative Details
Intraoperative considerations during inguinal repair include meticulous attention to spermatic
cord structures. A "no-touch" approach to the reactive testicular vessels and delicate vasa helps
minimize complications. Excessive dissection around the testicular vessels may result in
thrombophlebitis of the pampiniform plexus. The distal processus is spatulated widely to
provide free drainage of scrotal fluid. The proximal processus is ligated above (deep to) the
internal inguinal ring. Failure to identify a patent processus during inguinal exploration should
prompt (1) a thorough reexamination of the cord structures and (2) partial or complete excision
of the hydrocele or needle aspiration of only the hydrocele prior to closing.
During scrotal approaches, excision of redundant tunica vaginalis (with or without eversion) and
suturing of the reflected tunica behind the epididymis results in a postoperative testis that is
more easily and more reliably examined. Care must be taken to not injure the vas or epididymis
during this procedure. A running hemostatic suture around the line of excision is helpful for
assuring hemostasis. Plication of the sac (Lord procedure) is another technique useful for
management of large hydroceles. Electrocautery fulguration of the edge of the excised tunica
vaginalis promotes scarring and decreases recurrence while decreasing operative time.
Unexpected findings may be dealt with, as appropriate, either for the scrotal approach or by
converting to an inguinal approach (eg, testicular tumors). If a testicular tumor is encountered,
7

biopsy with frozen section and orchiectomy with resection of the spermatic cord up to the
internal ring is warranted if tumor is confirmed. Placing a drain in the dependent portion of the
scrotum is prudent for large hydroceles. A nonsuction drain such as a Penrose can be removed
within the first 24-48 hours after surgery. If a drain is not used, expect a large hematoma and
significant edema. Often, this enlargement is worse than the original problem, although it almost
always transient.
Postoperative Details
Children undergoing inguinal herniorrhaphies for repair of communicating hydroceles generally
recuperate with minimal discomfort and exceedingly few restrictions. Tub baths are to be
avoided for 5-7 days. The wounds of diaper-aged children are sealed with collodion,
Dermabond, or occlusive dressing. No activity restrictions are required, and nonnarcotic
analgesics are used minimally.
Patients undergoing scrotal approaches benefit from supportive dressings, such as fluff
dressings, in a scrotal support or athletic supporter. Rest and avoidance of vigorous activity help
minimize discomfort. Showers may be resumed within 24-48 hours. Occasional doses of
synthetic or semisynthetic narcotics may help relieve postoperative discomfort. Adult patients
should be counseled that the hydrocele may transiently reaccumulate for a month or so
postoperatively owing to edema.
Follow-up
At least one postoperative follow-up visit is recommended. For small infants, chronic recurring
hydroceles, or patients with unsuspected intraoperative findings, more protracted follow-up
evaluations may be warranted biweekly, monthly, or every 2-3 months to ensure complete
recovery and normal testicular size and architecture.
Complications
Complications are largely avoided with meticulous dissection and gentle tissue handling. In
addition, extensive dissection should be avoided, as it increases the risk for nerve damage,
vascular damage leading to testicular atrophy, and postoperative hematomas.

Injury to spermatic cord structures: The vas or testicular vessels may be injured in 1-3%
of inguinal approaches. Some testicular shrinkage has been described in nearly 10% of
children undergoing inguinal hernia repair.
Recurrence: Recurrence of the hydrocele after inguinal approaches is most often reactive
in nature and usually resolves within several months. Rarely, aspiration or scrotal surgery is
warranted.
Bleeding/scrotal hematoma: Either poor intraoperative hemostasis or excessive cord
dissection (with inguinal approaches) may result in postoperative bleeding. Hematomas
typically resolve over time. If the patient has evidence of ongoing bleeding or is extremely
symptomatic, exploration and hematoma evacuation is warranted.
Ilioinguinal/genitofemoral nerve injury: These nerves may be entrapped or divided
during inguinal approaches. The injury may be temporary or permanent.
Wound infection: Postoperative wound infections are quite uncommon, particularly in
children. Wound infections should be managed with antibiotics and, if necessary, opening the
wound.
Outcome and Prognosis
Inguinal repairs of communicating hydroceles are exceedingly successful, with a less than 1%
recurrence rate. If a unilateral approach is completed, the small but recognized risk for a
8

metachronous hydrocele or inguinal hernia developing remains, but the rate is likely less than
10%. Likewise, recurrence after tunica excision is also uncommon.
Future and Controversies
Recently, many surgeons have begun to advocate routine diagnostic laparoscopy of the
contralateral groin in patients (particularly children) with unilateral hernias. The premise is that
unsuspected contralateral hernias are repaired prior to clinical recognition. However, many more
patent processus are being ligated than true hernias are being repaired. Whether an increased use
of this technique will reduce the incidence of hydroceles in older children or adults remains to
be seen. Furthermore, whether utilization of this intraoperative modality is of any utility in
inguinal hydrocele repairs is open for debate.
Medical management, or, more importantly, prevention of patent processus vaginalis, has been
theorized as possible after full elucidation of the intricate molecular processes that control fetal
cell migration, proliferation, and adherence. Although the idea of preventing hydroceles or
indirect hernias is interesting, it is far from being applicable in clinical medicine.

REFERENCES
1. Manjunatha Y, Beeregowda Y, Bhaskaran A. Hydrocele of the canal of Nuck: imaging
findings. Acta Radiol Short Rep. 2012. 1(3).
2. Clarnette TD, Hutson JM. The genitofemoral nerve may link testicular inguinoscrotal
descent with congenital inguinal hernia. Aust N Z J Surg. 1996 Sep. 66(9):612-7.
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3. Chang YT, Lee JY, Wang JY, Chiou CS, Chang CC. Hydrocele of the spermatic cord in
infants and children: its particular characteristics. Urology. 2010 Jul. 76(1):82-6.
4. Clarke S. Pediatric inguinal hernia and hydrocele: an evidence-based review in the era of
minimal access surgery. J Laparoendosc Adv Surg Tech A. 2010 Apr. 20(3):305-9.
5. Lund L, Kloster A, Cao T. The long-term efficacy of hydrocele treatment with aspiration
and sclerotherapy with polidocanol compared to placebo: a prospective, double-blind,
randomized study. J Urol. 2014 May. 191(5):1347-50.
6. Saka R, Okuyama H, Sasaki T, Nose S, Yoneyama C, Tsukada R. Laparoscopic treatment
of pediatric hydrocele and the evaluation of the internal inguinal ring. J Laparoendosc
Adv Surg Tech A. 2014 Sep. 24(9):664-8.

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